HOLD MY HAND
Clifton Park Nursery School
“The Little
The enclosed registration
packet for the 2009-2010 schoolyear includes the
following forms:
1.
Registration Form
2.
Emergency Information Form
3.
Parents' Creed and Contract (2)
4.
Committee Preference Form
5.
Health Certificate
6. Delegation of
Parental Consent
Registrations will be
accepted on a first come, first served basis.
These forms must be accompanied by a non-refundable registration fee in
the amount of $50, in addition to
Advance May Tuition/Security Deposit of $45/75
made payable to Clifton Park Nursery School.
Your monthly tuition is $45/75, so the combined Registration Fee and May
Tuition deposit is $95/125. The September tuition is due by September 1st. The Advance
May Tuition/Security Deposit shall be refunded should the child be
withdrawn from school prior to September 1.It is important to note that your
position will be held only once all fees are paid and all forms (with the
exception of the Health Certificate) are filled out completely.
Please forward all forms and
registration fees to the Registrar at the following address:
Clifton Park Nursery
School
344 Moe Road
Clifton Park, NY 12065
The first days of school will
be Thursday, September 17 and Tuesday, September 22. Orientation will be held with the 3 year old
families on Tuesday, September 1 from 7:00 to 9:00pm at school. If you have any questions, or need further
information, please, do not hesitate to contact me.
If you decide not to
register your child after receiving the Registration Packet, please notify me
immediately.
Sincerely,
Samantha
Muscolino
Phone: 371-4026
E-mail:
sammuscolino@yahoo.com
HOLD MY HAND REGISTRATION FORM
Child's
Name__________________________________________________________________
Last
First
Middle
Nickname (if any)
Date of Birth ___________________________ Sex (circle) Male Female
Parents’ Names
___________________________________________________
Home
Address___________________________________________________________
Home Phone Number(s)________________________________Cell#_____________________
E-mail
Address___________________________________________________________
Parent Occupation __________________________ Bus.Phone
_________________
Work address_________________________________________________________________
Parent Occupation _______________________________ Bus.Phone _____________
Work
address__________________________________________________________________
Class Session Preferred
(Circle One Only):
Tuesday
AND Thursday Tuesday ONLY Thursday ONLY
Sibling
Information (if applicable):
Name_ Age(D.O.B.) School
_________________________________________________________________________
_________________________________________________________________________
Is there anything about
your child that would be helpful for the teacher to know in order to understand
and work with him/her better? Please,
take a moment to think about this. It is
very helpful information.
What do you want your child to gain from his/her
nursery school experience?
Does your child have any special fears?
What are your child's favorite activities?
How did you find out about our school?
Please, feel free to use the other side of the page to
elaborate on any comments you may have, below.
Clifton
Park Nursery School
HOLD MY HAND REGISTRATION FORM/EMERGENCY INFORMATION
Child’s
Name____________________________________________Child’s
Class________________
List
below three persons who could be contacted in case there is an emergency and
you cannot be reached. Please, be sure
they know their names are being given to us, and that they will be available if
needed.
1)
Name_________________________________________Relationship___________________
Address_________________________________________Phone________________________
2) Name_________________________________________Relationship___________________
Address_________________________________________Phone________________________
3)
Name_________________________________________Relationship___________________
Address_________________________________________Phone________________________
List
any allergies your child has.
List
any special needs your child has.
List
any medications your child takes on a daily basis.
List
any medical or physical limitations your child has.
Type of Hospitalization Insurance (Blue Cross Blue
Shield, CHP, Etc.)
_________________________________________________________________________
Policy
Holder’s Name_________________________________
Policy ID#_________________________________________
File No. (if
any)____________
Insurer’s
Phone and Address from back of insurance cad
_________________________________________________________________________
Doctor's
Name_____________________________________ Phone______________________
Clifton Park Nursery School
HOLD MY HAND PARENT CREED AND CONTRACT
We,
_______________________________________________________________, the parents of
______________________________,
understand that the Clifton Park Nursery School is a cooperative
school fully administered by the parents of the
enrolled children. As members of the Hold My Hand Program We agree to join this
cooperative and fulfill the duties thereof:
1.
To attend class with our child.
2.
To clean the classroom after class on a scheduled rotating basis.
3.
To provide transportation for our child to and from school at the designated
class times.
4.
To chaperone and provide transportation for field trips, as required.
5.
To actively serve on a standing committee or the executive committee (one
committee per family).
6.
To pay monthly tuition of $45 (1 day a week) or $75 (2 days a week) by the
first of each month. To pay a
late
fee of $10 after the first of the month.
7.
To provide a healthy snack and beverage for myself and our child.
8.
To follow the Constitution and By-laws of Clifton Park Nursery School.
9.
To participate in the CPNS fundraising as follows: collect at least one
donation worth $50 for the annual auction and to attend annual auction in
March. Families are encouraged to
participate in other fundraising events if they would like.
10.
To attend scheduled meetings as required.
11.
To notify the school at least one month prior to leaving the school should the
need to withdraw from the school
arise.
12.
To participate in school elections.
By signing this
contract, we agree to all of the above.
Parents' signatures
required:
___________________
_______________________________________
Signature Date
___________________
_______________________________________
Signature Date
Please keep one copy,
and return one copy.
Clifton Park Nursery School
HOLD MY HAND PARENT CREED AND CONTRACT
We,
_______________________________________________________________, the parents of
______________________________,
understand that the Clifton Park Nursery School is a cooperative
school fully administered by the parents of the
enrolled children. As members of the Hold My Hand Program We agree to join this
cooperative and fulfill the duties thereof:
1.
To attend class with our child.
2.
To clean the classroom after class on a scheduled rotating basis.
3.
To provide transportation for our child to and from school at the designated
class times.
4.
To chaperone and provide transportation for field trips, as required.
5.
To actively serve on a standing committee or the executive committee (one
committee per family).
6.
To pay monthly tuition of $45 (1 day a week) or $75 (2 days a week) by the
first of each month. To pay a
late
fee of $10 after the First of the month.
7.
To provide a healthy snack and beverage for myself and our child.
8.
To follow the Constitution and By-laws of Clifton Park Nursery School.
9.
To participate in the CPNS fundraising as follows: collect at least one
donation worth $50 for the annual auction and to attend annual auction in
March. Families are encouraged to
participate in other fundraising events if they would like.
10.
To attend scheduled meetings as required.
11.
To notify the school at least one month prior to leaving the school should the
need to withdraw from the school
arise.
12.
To participate in school elections.
By signing this
contract, we agree to all of the above.
Parents' signatures
required:
___________________
_______________________________________
Signature Date
___________________
_______________________________________
Signature Date
Please keep one copy,
and return one copy.
Clifton
Park Nursery School
HOLD MY HAND COMMITTEE PREFERENCE INFORMATION
Child's
Name _________________________________ Child’s Class_____________________
Home
Phone_______________________E-mail
address_______________________________
Parent’s
Names________________________________________________________________
Parent’s
Occupations___________________________________________________________
As a Cooperative Nursery
School, we all contribute to the general welfare of our school by serving on a
committee. No one person is overburdened with committee
responsibilities when each person does his or her share. This spirit of
cooperation ensures the smooth operation of our school as an effective learning
place for our children. Please, answer the following questions for both
parents. Thank you.
Do you have any
bookkeeping, web page or administrative skills?
___________________________
Do you have access to
professional discounts? If so, at which stores?_________________________
Do you have access to
snowplowing, landscaping or another building maintenance company? please specify)______________________________________
Are you a member of a
firehouse or other organization that has a hall available to the public? (please specify)______________________________________
Are there any other ways
in which your experience may help support our cooperative pre-school?
_____________________________________________________________________________
Please, read through
theses committee descriptions. Then please rank from 1 to 4 your interest in
these committees (1 most interested to 4 least interested). While we cannot guarantee that you will get
your first choices, we will endeavor to do our best to accommodate you.
____Fundraising
This is one of the most important committees.
While fundraising is everyone’s responsibility, a
separate fundraising committee is needed to
help with fundraising activities throughout the year, including the mandatory
annual Auction. Proceeds go toward maintenance of the buildings and grounds,
purchasing new equipment, and maintaining our school’s operations.
____Hospitality
This committee plans and oversees
social events, including the Welcome Picnic, Pumpkin Carving, and Pot Luck Dinner.
The members arrange for refreshments and paper products, and set-up/cleanup for
functions as
needed, and may work the refreshment table
during events. Please note that hospitality supplies (coffee, food, paper
products, etc.) are
purchased with school funds.
____Building and Grounds
Responsibilities of this committee include:
exterior painting, carpentry, gardening,
repair of playground equipment and toys,
raking, lawn mowing, and snow shoveling. The chairperson regularly inspects the
building and grounds for needed repairs and maintenance. Members may be called
upon prior to school start up if
immediate repairs are needed. Members are
assigned monthly lawn mowing or weekly snow shoveling duties as needed.
____Housekeeping/weekend cleaning
The members of this committee clean the school
each weekend on a
rotational basis. The cleaning takes place
any time between the end of the school day on Friday and 8 a.m. Monday. This
includes cleaning the sinks, lavatory, toys, chairs, and tables; vacuuming the
rugs; washing the floor; and one area of concentration which changes weekly to
ensure a thorough cleaning of our school.
Clifton Park
Nursery School
HOLD MY HAND HEALTH
CERTIFICATE
Please make sure this form is signed by a physician and returned to
Clifton Park Nursery School, 344 Moe Road, Clifton Park, NY 12065 no later than
September 1st .
Child's Name (please print)
_____________________________________________
Date of Birth: _____________Sex:
_____________Height: _____________Weight: _____________
1. Please indicate any findings on the
physical examination of this child, which should be brought to the attention of
the school.
2. If this child is to have any modification
or limitation of the physical activity in the school program, please indicate
the situation and the extent of such restrictions.
3. Please include any allergies or
reactions this child may have.
4. New York State requires certain
immunizations for children attending nursery or pre-kindergarten classes.
Please indicate
dates of the
following:
Oral Polio (3 or more
doses):I__________ II__________ III__________ Boosters _________ ________
DPT (3 or more doses): I__________
II__________ III__________ Boosters _________ ________
(Diphtheria, Tetanus, Whooping Cough.
DPT)
Measles:________________
Mumps:________________ Rubella:_________________
HIB:________________
(If given at age 15 months or older)
Hep B: I__________
II__________ III__________
(Required if born on or after 1/1/93 -
recommended for all children)
Varicella:_____________(required
for children born after 1/1/2000) OR Documentation as having had the disease by
a physician.
(If unsure documentation of serologic
immunity)
Pneumococcal Conjugate Vaccine (PCV7):_____________________(required for children born after
1/1/08)
Examining Physician (please print)
___________________________Date of Exam: _______________________________
Physician Signature:
_____________________________________________________
*Note: Examination must take place
within 1 year prior to the beginning of the school year.
Clifton
Park Nursery School
HOLD MY HAND DELEGATION OF PARENTAL CONSENT FOR MINOR
CHILDREN
Undersigned, being the
parent(s) of ______________________________________, a minor, do(does)
hereby authorize and empower Barbara Adams, Teacher of
the Clifton Park Nursery School, or her
designee, to be undersigned's agent and attorney-in-fact to
consent to such medical, dental, and surgical care and hospitalization as said
agent shall deem necessary for the above-named minor, provided the same is
recommended by and is rendered under the general or special supervision of any
physician, dentist, or surgeon (or insert the name of specific physician or
dentist desired)
________________________
or a hospital.
It is understood that
this delegation is given in advance of any specific need for treatment, but is
given to provide authority on the part of said agent to give specific consent
to any and all medical, dental, and/or surgical care and hospitalization which
the above-mentioned physician or surgeon of hospital may, in its best judgment,
deem advisable of said minor.
Any physician, dentist,
or surgeon or hospital, who has had delivered to it a copy of this delegation,
is
hereby requested to honor the consent of the aforesaid
agent for treatment to said minor to the same
extent as if said consent had been made by the
undersigned.
OPTIONAL: This authorization
shall remain effective until___________________________________
(up
to three years)
This section must be
completed in the presence of a Notary Public. ________________________ ____________________________________________ Date Parent ____________________________________________ Parent ___________________________________________ Address Sworn to before me this
_____________day of ___________________, ________. (Day)
(Month)
(Year) ___________________________________________ _____________________________ Notary Public
Telephone Number
Please list your
preferred doctor, dentist, and hospital:
Doctor:
________________________________________ Phone No.____________________
Dentist:
________________________________________ Phone No.____________________
Hospital:
_____________________________________________________________________